NCLEX-RN
NCLEX Psychosocial Integrity Questions
1. What action would the nurse take for a 4-year-old child who is called to the operating room for a planned myringotomy?
- A. Removing the child's undergarments
- B. Placing the child's toys on the bedside table
- C. Allowing the child to climb onto the stretcher
- D. Having the parents accompany the child to the operating suite
Correct answer: D
Rationale: The correct action is to have the parents accompany the child to the operating suite. Current practice encourages parents to stay with the child as long as possible to reduce stress related to a frightening experience. Removing the child's undergarments is usually not necessary for a myringotomy procedure. Placing the child's toys on the bedside table is important, especially a favorite one, for comfort until sedation is induced. Allowing the child to climb onto the stretcher may not be safe or appropriate as the child is too young to do so independently.
2. Which clinical findings indicate positive signs and symptoms of schizophrenia?
- A. Withdrawal, poverty of speech, inattentiveness
- B. Flat affect, decreased spontaneity, asocial behavior
- C. Hypomania, labile mood swings, episodes of euphoria
- D. Bizarre behavior, auditory hallucinations, loose associations
Correct answer: D
Rationale: The correct answer is bizarre behavior, auditory hallucinations, and loose associations. These are positive symptoms of schizophrenia, reflecting a distortion or excess of normal function. Withdrawal, poverty of speech, inattentiveness, flat affect, decreased spontaneity, and asocial behavior are negative symptoms linked to schizophrenia, indicating a diminution or absence of normal function. Hypomania, labile mood swings, and episodes of euphoria are more characteristic of bipolar disorder, rather than schizophrenia.
3. When a client with newly diagnosed chronic bronchitis tells the home health nurse about continuing to smoke 1 or 2 cigarettes a day and not doing the prescribed pulmonary physiotherapy exercises, which response by the nurse is best?
- A. ''Tell me about your typical day before you were diagnosed with chronic lung disease.''
- B. ''Smoking and not doing the exercises will make your lung disease continue to get worse.''
- C. 'I can't make you stop doing what you are doing, and it's your choice to be sick or well.''
- D. ''Your shortness of breath is probably because of your smoking and not doing the exercises.''
Correct answer: A
Rationale: Asking the client to describe a typical day is the best response. More data are needed about the client's usual activities of daily living so that the plan can be adapted to the client's preferences. The statement indicating that smoking and not doing the pulmonary exercises will allow the lung disease to progress is probably not news to the client and does not help in determining factors that might be contributing to nonadherence. The statement that the nurse cannot stop the client's behaviors indicates that the client is to blame and will place the client on the defensive. The statement that the client's dyspnea is caused by smoking and not doing the pulmonary exercises places the client on the defensive and will decrease trust, preventing the nurse from obtaining more information about why the client is nonadherent with the treatment plan.
4. The nurse is assessing a young client who presents with recurrent gastrointestinal disorders. On further assessment, the nurse learns that the client is experiencing job-related pressures. Which is the most important nursing intervention for this client?
- A. Educate the client on managing stress.
- B. Teach the client to maintain a balanced diet.
- C. Instruct the client to have regular health checkups.
- D. Ask the client to use sunscreen when working outdoors.
Correct answer: A
Rationale: The most important nursing intervention for a client experiencing job-related pressures and recurrent gastrointestinal disorders is to educate the client on managing stress. Stress is a lifestyle risk factor that can impact both mental health and physical well-being. It is associated with various illnesses, including gastrointestinal disorders. Teaching the client to maintain a balanced diet is important for preventive care and health promotion but is not the priority in this scenario. While instructing the client to have regular health checkups is essential for overall health maintenance, addressing the root cause of stress is crucial in this case. Asking the client to use sunscreen when working outdoors is important for sun protection and skin cancer prevention but not directly related to the client's job-related stress and gastrointestinal issues.
5. A terminally ill client repeatedly talks about her son's upcoming wedding and how much she wants to attend. Which stage of the K�bler-Ross theory of death and dying is the client displaying?
- A. Anger
- B. Denial
- C. Bargaining
- D. Acceptance
Correct answer: C
Rationale: The client is displaying the stage of bargaining in the K�bler-Ross theory of death and dying. During the bargaining stage, individuals attempt to negotiate for more time or a different outcome in the face of impending death. In this scenario, the client expressing a desire to attend her son's wedding and discussing it frequently reflects a form of bargaining for additional time to be present for the event. Anger, on the other hand, involves extreme expressions of emotion ranging from irritation to rage. Denial is characterized by an inability to accept the reality of the situation. Acceptance signifies coming to terms with the circumstances and may lead to decreased interest in people and surroundings.
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